In tsunami's wake, top priorities are treating trauma, ensuring clean water and limiting infections

After the surging ocean waters spawned by Japan's magnitude 8.9 earthquake receded from that country's northeast coast, the drowned were only the first victims to be counted.

Over the next several days, physicians and public health officials in Japan can expect to contend with a second wave of tsunami victims with aspiration-related illness and trauma and crush wounds, as well as with the threat of disease spread by contaminated water. Over the long run, the horrors and bolt-from-the-blue devastation of a tsunami leave indelible psychological scars on the surviving population.

The Dec. 26, 2004, tsunami that first struck Thailand's southwest coast and rolled on across the Indian Ocean gave public health officials worldwide plenty of data and case studies to guide their disaster preparations.

In a letter published in the New England Journal of Medicine, physicians at a regional hospital in hard-hit Phangnga, Thailand, underscored that while drowning claims the greatest share of fatalities, a tsunami's wall of water also inflicts head injuries, fractures and lacerations as it slams together debris, human bodies and stationary objects. In the week following the tsunami, physicians at the Takuapa General Hospital reported that they treated 2,285 patients with trauma -- 11% of those cases categorized as serious, and 17% considered intermediate trauma.

Dr. Lee Weiss, regional medical director of Emergent Medical Associates in Manhattan Beach, Calif., says the wounds that victims sustain in earthquakes and tsunamis tend to bring both insult and injury. In addition to broken bones and lacerations, the flesh surrounding victims' wounds is often crushed by falling or floating debris, cutting off blood supply and causing muscle to die in hurt limbs. The result: Once victims reach a hospital, amputation is often the only course possible.

No surprise, then, that the Takuapa Hospital's four operating rooms were in use round the clock as physicians cleaned wounds, amputated limbs and stanched internal bleeding in a total of 683 operations. In short order, many of the hospital's surgical patients developed foul-smelling infections, necessitating the addition of an amoebicide and anti-protozoal medication (metronidazole) to their routine regimens of antibiotics, they reported.

A May 2005 study that looked at 17 critically-injured 2004 tsunami victims who were evacuated to Europe underscored that when humans are caught in the agitation of water picking up everything in its path, their wounds can end up colonized by unusual nasties: In addition to the usual bacteriological suspects, authors of the study found many strains of bacteria that are resistant to multiple front-line antibiotics.

Outside the hospital, meanwhile, "the misery index starts to rise considerably" as flood waters recede and the dead are buried, says Weiss.

Public health officials often struggle with water treament systems and tap-water distribution systems that have been overwhelmed or contaminated by ocean water and by oil, gas, pesticides and decaying animals carried inland by the tsunami. "There's a very high likelihood of cross contamination of waste water and treated water," says civil engineering professor Kripa Singh of the University of New Brunswick in Canada, who has studied how water treatment and distribution systems fare in disasters.

Often, distribution pipes, which supply tap water, are first cracked or broken by earthquake forces, said Singh. Once water carried in by a tsunami breaches that system, it can become a source of illness even inland, he said. Weiss said that while cholera and typhoid are unlikely in a country as developed as Japan, outbreaks still can happen -- and more common gastrointestinal illnesses from contaminated water can make life miserable for uprooted and often grieving victims.

Even after the initial dangers have passed, the psychological fallout of widespread natural disaster can be huge, as well. Six months after the 2004 tsunami receded in Sri Lanka, a study found that among 264 adult survivors living in temporary housing, 56% met the clinical criterai for post-traumatic stress disorder.

"This should really get equal billing" with some of disasters' most acute effects, says Weiss. "As the shock of this wears off, there’s going to be terrible depression, terrible grief for those lost, and hopelessness in a country that’s had a terribly battered economy for 12 years now. You'll see more suicides, more physical ailments as people fail to eat properly or take care of themselves."